Your Medical Records

How information is extracted from medical records for auditing to ensure clinical services are maintained is changing. Click here for more information: GP Fair Processing Notice v3

Your Medical Records

We need to hold personal information about you on our computer system and in paper records to help us to look after your health needs. The Overton Park Surgery is committed to the accuracy and security of patient information. All information about you is held securely and appropriate safeguards are in place to prevent accidental loss.

There is strict guidance in place governing the use of, access to, and distribution of medical records that all healthcare professionals, from Consultants and Practice Managers to Administrators and Receptionists, must adhere to.

From time to time, it may be necessary to share information with others involved in your care. Anyone with access to your record is properly trained in confidentiality issues and is governed by both a legal and contractual duty to keep your details private.

In some circumstances we may be required by law to release your details to statutory or other official bodies, for example if a court order is presented, or in the case of public health issues. In other circumstances you may be required to give written consent before information is released – such as for medical reports for insurance, solicitors etc.

To ensure your privacy, we will not disclose information over the telephone or fax unless we are sure that we are talking to you.

Information will not be disclosed to family, friends, or spouses unless we have prior written consent, and we do not leave messages with others.

Currently there are three ways that your information may be shared outside of Overton Park, and you can give consent to each individually. If we do not have your explicit consent, we assume that you do not consent and do not share your information.

The Summary Care Record and the sharing of basic information helps clinicians in A&E Departments and ‘Out of Hours’ health services to give you safe, timely and effective treatment. Your patient record will be held securely on confidentially on our electronic system, and will only be accessed by authorised healthcare professionals directly involved in your care.

You will be asked if healthcare staff can look at your information every time they need to, unless it is an emergency and they are unable to; for instance if you are unconscious.

1. Summary Care Record

This is used nationally across England, and contains basic information about your current medications; any allergies you have; any bad reactions you have had to medicines.

Overton Park Surgery recommends that you have an 'SCR with additional information', especially if you have any ongoing health conditions. This longer SCR lists your active conditions; significant procedures you have undergone; anticipatory care information; end of life care information; and your immunisation history.

Summary Care Record Leaflet - Information for patients on what an SCR is for and the choices you have as to what parts of your record, if any, you include.

Summary Care Record OPT OUT Form - If you do not wish to have an SCR, you can opt-out of having one. Please complete this form and hand it in to the Reception desk.

2. JUYI

"Joining Up Your Information" - this is Gloucestershire's shared health and social care record, and only relates to the Gloucestershire area. It is more detailed than an SCR, with information held by NHS organisations other than your GP surgery.

This is specific to TPP SystmOne, the clinical system that Overton Park and multiple other medical services use. There are two parts: Sharing Out and Sharing In.

If you consent to Sharing Out, then services using TPP have access to entries that have been made here at Overton Park. If you consent to Sharing In, Overton Park will have access to entries made at other services that use TPP.

You have a right to see your records if you wish. Please ask at reception if you would like further details and our patient information leaflet. In some circumstances a fee may be payable.

Data Use and Patient Choice

Data is recorded and used by health and care professionals to help make diagnoses and decisions about patient care. This usage can be:

'For individual care and treatment', such as one specialist consulting with another regarding a patient.

'For purposes beyond individual care and treatment'

This means for research purposes and to plan services, and involves monitoring the outcomes of new treatments, studying patterns and trends, and predicting what services will be needed in the future so that funding and resources can be put in place. This data is anonymised before it can be used.

For any data to be used beyond the patient's individual care and treatment, there should be a benefit to the health and care system, and must never be used for insurance or marketing purposes without the patient's explicit consent.

Your Data Matters to the NHS

If you do not want your confidential patient information to be used for purposes beyond individual care and treatment, you can opt-out. You can change your mind and update your national data opt-out choice at any time.

All NHS organisations are expected to participate and support health and care research. The Health Research Authority set standards to NHS organisations to make sure they protect your privacy and comply with the law when they are involved with research. You may be asked to take part in studies, and told what data from your record will be used and how before you make a decision. The information will be depersonalised wherever possible so that you cannot be identified. Researchers may seek special approval for collecting anonymised data if it is not possible for patient agreement to be gained as the sample size is too large - such as for national projects.

There are strict requirements around using confidential patient data in research for public interest. If you still have concerns or questions, you can contact the NHS Health Research Authority using the following link.